MEDICAL HISTORY / CONSENT & RELEASE

Please explain any items checked and note any other special health considerations:

Date of last tetanus shot:
MM/DD/YYYY

I hereby authorize the participation of the above-named child in activities of New Community Church at NCC Kids Soccer Camp. In consideration of New Community Church providing these activities, I, on behalf of myself and other parents and guardians of the minor, do hereby release New Community Church, its officers, employees, agents, and members of the Board of Elders from all claims and causes of action by reason of any injury which may be sustained as a result of these church activities, whether on the church premises or on the way to or from these activities. I agree to direct my child to cooperate and to conform with directions and instructions of personnel of the organization in charge of these activities. Should my child not do so, and should those leading an activity believe it necessary, I will come and remove my child from the activity as soon as possible after being called by a staff representative for that purpose.

I hereby give my permission to the physician, nurse, dentist or hospital selected by New Community Church to secure medical or dental aid as required for illness or injury under a physician's orders, including transportation to and from necessary facilities. As a participant, I understand New Community Church is not obligated to carry any insurance to cover those medical and/or dental expenses.

This authorization shall remain effective until revoked in writing and delivered to New Community Church.
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Check this box if you agree with the above medical release statement.

In addition, by checking the box below you acknowledge the use of Chesterfield Presbyterian Church (CPC) facilities is at your own risk and as a result waive any claim against CPC, their officers or staff for any injuries, accidents or damages from the use of the facilities.
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